Next Page

Kwashiorkor (Protein-Calorie Malnutrition)

"Kwashiorkor" is the name given to the protein-calorie malnutrition that is so common in early childhood throughout the tropics. It is characterized by edema and failure to thrive, depigmentation, hyperkeratosis, and red hair. Some authors have translated "kwashiorkor" as meaning "the red boy" or "red-haired boy" in the Ga language of the Accra region (Ghana). Recent discussions with physicians in Kumasi (P.E.S.P. 1998) show that it does not literally mean "red hair." It is a Ga word which describes the malnourished child, the result of the ill-health which develops when an infant is weaned from breast-feeding (which may be at about 2 years of age). When a sibling is born and monopolizes breast feeding, the "weanling" or deposed child may develop kwashiorkor, an all-embracing word for the clinical syndrome of malnourishment in which reddening of the child's hair is but a part. While this name was first used in West Africa, kwashiorkor is seen throughout Africa, Asia, and the tropics, but it varies considerably. Everywhere it is a complex pattern of malnutrition: in kwashiorkor the diet is principally low in protein, whereas in marasmus it is a lack of calories; protein-calorie malnutrition is the generic term used in the tropics for the whole range of malnutrition in childhood. Nowhere is malnutrition a straightforward deficit of just one component. Malnutrition is a spectrum and the clinical result is as variable as the foods that are eaten ... or lacking. Sorrow, ill-health, and often death are its constant companions.

Synonyms

Kwashiorkor. Nutritional edema syndrome. Malignant malnutrition. Protein-calorie deficiency. Obwosi (Uganda). Diboba, m'buaki (Democratic Republic of Congo). Culebrilla (Mexico). Pellagroide beriberico (Cuba). Sp: Culebrilla. Dystrofia pluricarencial. Fr: Enfants rouges. Boufissure D'Annam. Syndrome pigmentation oèdeme. Ger: Kwashiorkor. Mehlnahrschäden.

Definition

Kwashiorkor is a state of malnutrition that results from a deficiency of dietary protein in the presence of a normal or high carbohydrate intake. As indicated above, it must be differentiated from marasmus, which occurs when the diet is of normal quality but insufficient; the latter may be infantile, occurring before 1 year, or late, occurring in an older child. Both patterns of malnutrition can develop together, resulting in marasmic-kwashiorkor; there are varying definitions based on the different clinical stages.

Etiology and Pathology

Kwashiorkor is most common between the ages of 1 and 4 years, but can occur in infancy; it is seen with equal frequency in both sexes. It may also occur in adult life, when it is almost invariably a complication of some parasitic or other infection (e.g., strongyloidiasis). There are many causes of kwashiorkor, but weaning is the major factor, when breast milk is replaced by an inadequate and often unbalanced diet. Infants are most frequently affected in times of famine, when their mother is also starved for protein. After the age of 1 year, kwashiorkor may occur even when there is no food shortage, because tribal custom or ignorance may not provide the right nutritional balance. Many children have managed to maintain a barely adequate nutrition, which is then disturbed by illness, either an infection such as tuberculosis or parasites such as hookworm or Ascaris. Even measles or a urinary tract infection may be sufficient to tip the balance between good nutrition and malnutrition.

A link between kwashiorkor and aflotoxins has been suggested because aflotoxin and its metabolites are found in the liver, blood, and urine of children with kwashiorkor but very seldom in marasmic children. While this may be valid in some areas, it is unlikely that there is only one way to develop kwashiorkor.

Kwashiorkor is most common where the staple diet is cereal, either cassava, rice, yams, or plantains. The supply of protein is almost always minimal in these countries and may all too easily fall below the child's requirements. To the protein deficiency must be added a lack of vitamins, varying in each country but often involving riboflavin or vitamin A in particular; folic acid may also be insufficient.

Pathologically, the most marked finding is gross muscle wasting, often masked by edema. The skin is usually hyperkeratotic, usually depigmented and may scale or slough: secondary septic lesions are common on all parts of the body. The intestine will be "paper thin", translucent and white, with atrophy of both the muscle and mucosa: the villi may be flat. The liver is enlarged, yellow-brown, and greasy to touch at autopsy. The liver cells are distended with liquid and, where malaria is endemic, there will be superimposed malarial pigment in Kupffer cells and in macrophages of the portal tracts. Despite these gross changes, the liver function tests often remain normal. There is likely to be severe pancreatic atrophy and poor renal function in many patients. Although children with kwashiorkor have clinical cardiac and cerebral abnormalities, changes in the heart and brain are not obvious at autopsy or even on microscopy.

Laboratory Diagnosis

Metabolic changes are severe in kwashiorkor, particularly a deficiency of amino acids. There are numerous sophisticated tests to establish this, but more routine tests will show a low total plasma protein level, with a profound decrease in plasma albumin, often below 1 g per 100 ml. Alpha and beta globulin are also low, but gammaglobulin is frequently raised as a result of recurrent infection.
Potassium depletion can be severe, as low as 1 mg per 100 ml. Sodium and chloride are elevated. The blood urea is likely to be low and measurement of the 24 hour excretion of creatinine in the urine provides a good way of assessing the actual protein deficiency.

The protein deficiency causes a mild anemia, which responds to a high protein diet; however, many children are also anemic for other reasons such as parasites (e.g., hookworms) or chronic sepsis.

Back to the Table of Contents

Copyright: Palmer and Reeder

Tropical Medicine Mission Index of Diseases About Tropical Medicine Tropical Medicine Home Page Tropical Medicine Staff